Atrial Fibrillation: (Adapted from the 2006 ACC/AHA - CardioSource

56 Pages·2011·0.48 MB·English

ACCF/AHA Pocket Guideline
Management
of Patients With
Atrial
Fibrillation
(Adapted from the 2006 ACC/AHA/ESC Guideline and the
2011 ACCF/AHA/HRS Focused Updates)
© 2011 American College of Cardiology Foundation and American Heart Association, Inc.
The following material was adapted from the 2011 ACCF/AHA/HRS Focused Updates
Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients with
Atrial Fibrillation: a report of the American College of Cardiology Foundation/American
Heart Association Task Force on Practice Guidelines developed in partnership with the
European Society of Cardiology and in collaboration with the European Heart Rhythm
Association and the Heart Rhythm Society. This is available on the World Wide Web sites
of the American College of Cardiology (www.cardiosource.org) and the American Heart
Association (my.americanheart.org).
For a copy of the full report or published executive summary, visit the 2006 ACC/AHA/ESC
Guidelines for the Management of Patients with Atrial Fibrillation (J Am Coll Cardiol
2006;48:854-906) and the 2011 ACCF/AHA/HRS Focused Updates (J Am Coll Cardiol, 2011;
57:223-242 and J Am Coll Cardiol, 2011; 57:1330-1337).
For copies of this document, please contact Elsevier Inc. Reprint Department, e-mail:
[email protected]; phone: [phone]; fax: [phone].
Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of
this document are not permitted without the express permission of the American College
of Cardiology Foundation. Please contact Elsevier’s permission department at
[email protected].
Contents
1. Introduction.......................................................2
2. Classification of AF.................................................6 Classification
3. Epidemiology and Prognosis ........................................8 Epi/Prognosis
4A... CClliinnicicala.Hl iEstvoarylu.aantdio.Pnh y..s.ic.a.l..E.xa.m..in.a.ti.o.n.......................................................................99 Clinical Eval.
5. Proposed Management Strategies ................................... 11
AB....SOtvraetrevgieiwc..Oobf.jAelcgtoivreitsh.m..s..fo.r..M..a.n.ag.e.m..e.nt..o.f..P.a.t.ie.n.ts...W.it.h..A.F..........................................1121 Managem
CFDE......R..EPPicshhhkaao.rrSmmctaraaarccdtooiifollioocgaggratiiccipoaanhll...yEC...an.anhr.dda.in.oR.cv.iese.mkrs..eSi.ontn.rta....ot..iff.i..Dc..airt..eio..cnt..-...C....u...rr...e...nt....C......ar...d...io...v...e...rs...i...o...n.........................................................................22216837 ent Strategies
G..Catheter.Ablation....................................................30
6. Recommendations ................................................30
A..Pharmacological.Rate.Control.During.AF.(Updated)............................30
B..Preventing.Thromboembolism.(Updated)...................................33
C..Cardioversion.of.AF.................................................. 37
D..Sinus.Rhythm.(Updated)...............................................42
E..Postoperative.AF....................................................44
GF...A.Mcuantea.gMeymoecnatr.doiaf.lA.IFn.fAarscstoiocnia..te.d...W.it.h........................................45 Recom
m
IH.....HMthyaepn.eWargtohelfymfr-oPeinadtri.skominf.sA..o.Fn..D-.Wu.rh.ini.tge...P.Pr.ree.g-.enx.acn.ic.tay.t.i..o..n...S..y..n..d..ro..m....e...............................................................................444687 endations
J...Management.of.AF.in.Patients.With.Hypertrophic.Cardiomyopathy.................49
K..Management.of.AF.in.Patients.With.Pulmonary.Disease.........................50
1. Introduction
Atrial.fibrillation.(AF).is.a.supraventricular.tachyarrhythmia.
characterized.by.uncoordinated.atrial.activation.with.consequent.
deterioration.of.mechanical.function..AF.is.the.most.common.
sustained.cardiac.rhythm.disturbance,.increasing.in.prevalence.with.
Clinical Eval. asdugisbee.sa.tAsaFen..ti.isHa.loe.pmftreoonpd.oaynrstsaioomnci.icoa.fti.mepdap.twaieiirtnmht.ses.ntwrtu.itachnt.udAr.Fath.lh.rhoaemvaebr.tno.doei.msdeebatoselecic.ta.aelbtvhleeon.uhtgse.har.at..
related.to.AF.result.in.significant.morbidity,.mortality,.and.cost..
Accordingly,.these.writing.committees.were.initiated.to.establish.
guidelines.for.optimum.management.of.this.frequent.and.complex.
arrhythmia..
The.pocket.guide.was.originally.derived.from.the.executive.summary.
of.the.ACC/AHA/ESC Guidelines for the Management of Patients With
Atrial Fibrillation..These.guidelines.were.first.published.in.2001,.revised.
in.2006.and.two.focused.updates.were.published.in.2011..This.text.
provides.a.more.detailed.explanation.of.the.management.of.AF,.along.
with.appropriate.caveats.and.levels.of.evidence..Both.the.full-text.
guidelines.and.the.executive.summary.are.available.online,.at.http://
www.cardiosource.org.and.http://www.my.americanheart.org..Users.of.
this.pocket.guide.should.consult.those.documents.for.additional.
information.
2
Scope of the Pocket Guide
The.2006 Guidelines for the Management of Patients With Atrial
Fibrillation.and.2011 Focused Updates.cannot.be.reproduced.in.their.
entirety.in.a.pocket.guide.format..For.this.reason,.the.pocket.guide.
focuses.on.issues.most.frequently.encountered.in.clinical.practice:
n.Newly.Discovered.AF
n.Recurrent.Paroxysmal.AF
n.Recurrent.Persistent.AF
n.Permanent.AF
n.Maintenance.of.Sinus.Rhythm
n.Avoidance.of.Stroke.and.Other.Symptoms.Leading.to.Hospitalization
Classification of Recommendations
A.classification.of.recommendation.and.a.level.of.evidence.have.been.
assigned.to.each.recommendation..Classifications.of.recommen-
dations.and.levels.of.evidence.are.expressed.in.the.updated.ACCF/
AHA.format.as.described.in.more.detail.in.Table 1.
3
Table 1. Applying Classification of
Recommendations and Level of Evidence
SIzE oF TREATMEnT EFFECT
CLAss I CLAss IIA
Benefit >>> Risk Benefit >> Risk
Procedure/Treatment Additional studies with
SHOULD be performed/ focused objectives needed
administered IT IS REASOnAbLE to per-
form procedure/administer
treatment
t
eC LeveL A n Recommendation that n Recommendation in favor
FF Multiple populations procedure or treatment of treatment or procedure
t e evaluated* is useful/effective being useful/effective
en Data derived from multiple n Sufficient evidence from n Some conflicting evidence
tM randomized chlinical trials multiple randomized trials from multiple randomized
eA or meta-analyses or meta-analyses trials or meta-analyses
r
t
F
on) o LLiemviteeLd Bpopulations pnr oRceecdoumrem oern dtraetaiotmn ethnat t onf Rtreecaotmmmenetn odra ptiroonc eind ufarev or
sI evaluated* is useful/effective being useful/effective
eCI Data derived from a n Evidence from single n Some conflicting evidence
Pr single randomized trial or randomized trial or nonran- from single randomized trial
y ( nonrandomized studies domized studies or nonrandomized studies
t
n
AI
rt LeveL C n Recommendation that n Recommendation in favor
Ce Very limited populations procedure or treatment is of treatment or procedure
oF evaluated* useful/effective being useful/effective
te Only consensus opinion n Only expert opinion, case n Only diverging expert
MA of experts, case studies, studies, or standard of care opinion, case studies,
tI or standard of care or standard of care
s
e
Suggested phrases for should is reasonable
writing recommendations is recommended can be useful/effective/beneficial
is indicated is probably recommended
is useful/effective/beneficial or indicated
Comparative effectiveness treatment/strategy A is treatment/strategy A is probably
phrases† recommended/indicated in recommended/indicated in perfer-
preference to treatment B ence to treatmet B
treatment A should be chosen it is reasonable to choose treatment
over treatment B A over treatment B
4
Class IIb Class III No Benefit *Data available from clinical trials or
Benefit ≥ Risk or Class III Harm registries about the usefulness/
Additional studies with broad Procedure/ efficacy in different subpopulations,
objectives needed; additional Test Treatment such as sex, age, history of diabetes,
registry data would be helpful CnOo Rb eIInI:e fit nHeeltp ful nbeon Perfiotven history of prior myocardial infarction,
Procedure/Treatment COR III: Excess Cost Harmful history of heart failure, and prior
MAy bE COnSIDERED Harm w/o benefit to Patients aspirin use. A recommendation with
or Harmful Level of Evidence B or C does not
n Recommendation’s n Recommendation that imply that the recommendation is
usefulness/efficacy less procedure or treatment is weak. Many important clinical
well established not useful/effective and questions addressed in the guidelines
n Greater conflicting may be harmful dtroia nlso.t A leltnhdo utghhem rasnedlvoems itzoe dc ltinriiaclasl are
evidence from multiple n Sufficient evidence from unavailable, there may be a very clear
randomized trials or multiple randomized trials clinical consensus that a particular
meta-analyses or meta-analyses test or therapy is useful or effective.
n Recommendation’s n Recommendation that † For comparative effectiveness
usefulness/efficacy less procedure or treatment is recommendations (Class I and IIa;
well established not useful/effective and Level of Evidence A and B only),
n Greater conflicting may be harmful cstoumdpieasr athtoart vseurpbpso srth tohueld u isnev oolfv e
evidence from single n Evidence from single
direct comparisons of the treatments
randomized trial or randomized trial or
or strategies being evaluated.
nonrandomized studies nonrandomized studies
n Recommendation’s n Recommendation that
usefulness/efficacy less procedure or treatment is
well established not useful/effective and
n Only diverging expert may be harmful
opinion, case studies, or n Only expert opinion, case
standard of care studies, or standard of care
may/might be considered COR III: COR III:
NO Benefit Harm
may/might be reasonable
is not Potentially
usefulness/effectiveness is recommended harmful
uwneklln eoswtanb/ulinshcleeda r/uncertain or not sish onuoltd i nndoitc ated caassuosceisa theadr mwith Recom
eibbsfee fn nedoceottfi invuceeisa el/fu l/ eisbthxyec/o mdeuoslodnsr e tnmaoloitt rybid- mendations
5
Classification 2. Classification of AF
Various.classification.systems.have.been.proposed.for.AF.based.on.
the.ECG.pattern,.epicardial.or.endocavitary.recordings,.mapping.
of atrial.electrical.activity.or.clinical.features..Although.the.pattern.of.
AF.can.change.over.time,.it.may.be.helpful.to.characterize.the.
arrhythmia.at.a.given.moment..The.classification.scheme.
recommended.here.represents.a.consensus.driven.by.a.desire.for.
simplicity.and.clinical.relevance.
The.clinician.should.distinguish.a.first-detected.episode.of.AF,.whether.
or.not.symptomatic.or.self-limited,.recognizing.the.uncertainty.about.
the.actual.duration.of.the.episode.and.about.previous.undetected.
episodes.(Figure 1)..After.2.or.more.episodes,.AF.is.considered.
recurrent..If.the.arrhythmia.terminates.spontaneously,.recurrent.AF.is.
designated.paroxysmal;.when.sustained.beyond.7.days,.it.is.termed.
persistent..Termination.with.pharmacological.therapy.or.direct-current.
cardioversion.does.not.alter.the.designation..First.detected.AF.may.be.
either.paroxysmal.or.persistent..The.category.of.persistent.AF.also.
includes.cases.of.long-standing.AF.(e.g.,.>1.year),.usually.leading.to.
permanent.AF,.in.which.cardioversion.has.failed.or.has.been.foregone..
These.categories.are.not.mutually.exclusive..One.patient.may.have.
several.episodes.of.paroxysmal.AF.and.occasional.persistent.AF,.or.
the.reverse..It.is.practical.to.categorize.a.given.patient.by.their.most.
frequent.presentation..The.definition.of.permanent.AF.is.often.arbitrary,.
and.the.duration.refers.both.to.individual.episodes.and.to.how.long.
the.diagnosis.has.been.present.in.a.given.patient..Thus,.in.a.patient.
with.paroxysmal.AF,.episodes.lasting.seconds.to.hours.may.occur.
repeatedly.for.years.
6
This.terminology.applies.to.episodes.lasting.more.than.30.seconds.
wmhyiytphoeocruathtr.dyari.aorlei.divniesfarmsrci,b.tolieor..nac.ca(MuutsIe)e,...pc.Sualermdciooanncad.srauyrr.ydg.ieAsrFey.a,i.nsp.eet.hriisec..acsroedntittsiinisdg,.e.morefy.doa.ccsuaetrpeda.itriast,e.ly.. Classification
Then.AF.is.not.the.primary.problem,.and.treatment.of.the.underlying.
disorder.usually.terminates.the.arrhythmia..Conversely,.when.AF.
occurs.in.the.course.of.a.concurrent.disorder.like.well-controlled.
hypothyroidism,.the.general.principles.for.management.of.the.
arrhythmia.apply.
The.term.lone.AF.applies.to.individuals.under.60.years.old.without.
clinical.or.echocardiographic.evidence.of.cardiopulmonary.disease,.
including.hypertension..These.patients.have.a.favorable.prognosis.
with.respect.to.thromboembolism.and.mortality..Over.time,.patients. M
move.out.of.the.lone.AF.category.due.to.aging.or.development.of. anagem
crreiasfkredsris.ao.ctfo..ta.hcbranosomersbm.owa-lieitthmieosbu.ots.lurishcmehu..aamsna.det.inmcl.aomrrgittearmalitl.yev.naritls.voeef....dtThihseee.l.aetesftre.ma,.tp.rniruoomsntv,h.aaelvntiudcl..athhre.eAa.rFt.. ent Strategies
valve.or.valve.repair.
Figure 1. Patterns of Atrial Fibrillation
First detected
(SPealfr-otexyrmsminaalt1in,4g) (Not Pseerlfs-itsetermntin2,a4ting) Recom
m
Permanent3 endations
1 Episodes that generally last ≤ 7 days (most < 24 h);
2 usually more than 7 days;
3 cardioversion failed or not attempted; and
4 both paroxysmal and persistent AF may be recurrent.
7
3. Epidemiology and Prognosis
AF.is.the.most.common.arrhythmia.in.clinical.practice,.accounting.for.
Epi/Prognosis ad4p.is5pt.umrorbixllaiimonnac.teinesl..yt.h.Aoenn..Eeeu-strthoimiprdea.atoenfd..hU.2on.s3iop.mnit.ahilllaiizovanet.i.popenaosro.pfxoleyr.s.icnma.Nardlo.ioartrch..p.rAehmrysteihsrmtiec.nat.a.AnFd...
During.the.last.20.years,.hospital.admissions.for.AF.have.increased.by.
66%.due.to.the.aging.of.the.population,.a.rising.prevalence.of.chronic.
heart.disease,.more.frequent.diagnosis.through.use.of.ambulatory.
monitoring.devices.and.other.factors..
8